Worksheet D, Part I
- Return to Cost Report Summary
- Form D001
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3530.1, REV 12
BARNSDALL NURSING HOME
BARNSDALL, OK 74002
BARNSDALL, OK 74002
Medicare Provider Number: 375482
Cost report status: Settled Without Audit
[Record Code 362742 - 1996]
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APPORTIONMENT OF ANCILLARY AND OUTPATIENT COST AND REDUCTION OF THERAPY COST COSTS | PROVIDER NO: 375482 |
PERIOD: FROM 07/01/2008 TO 06/30/2009 |
WORKSHEET D Part I |
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SNF - SNF Medicare - Title XVIII | |||||||||||
PART I - CALCULATION OF ANCILLARY AND OUTPATIENT COST | |||||||||||
Cost Center | RATIO OF COST TO CHARGES (Fr. Wkst. C Column 3) |
HEALTH CARE PROGRAM CHARGES |
HEALTH CARE PROGRAM COST |
TITLE XVIII CHARGES ON AND AFTER 1/1/1998 |
PART B THERAPY COSTS ON AND AFTER 1/1/1998 Col. 1 X 6) |
10% REDUCTION OF THERAPY (Col. 7 X 10%) |
NET ALLOWABLE PART B COSTS Col. 5 less Col. 8) |
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Part A | Part B | Part A (Col. 1 X Col. 2) |
Part B (Col. 1 X Col. 3) |
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1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||
ANCILLARY SERVICE COST CENTERS | |||||||||||
21 | Radiology | 21 | |||||||||
22 | Laboratory | 22 | |||||||||
23 | Intravenous Therapy | 23 | |||||||||
24 | Oxygen (Inhalation) Therapy | 24 | |||||||||
25 | Physical Therapy | ### | ### | 25 | |||||||
26 | Occupational Therapy | ### | ### | 26 | |||||||
27 | Speech Pathology | ### | ### | 27 | |||||||
28 | Electrocardiology | 28 | |||||||||
29 | Medical Supplies Charged To Patients | 29 | |||||||||
30 | Drugs Charged to Patients | ### | ### | 30 | |||||||
31 | Dental Care - Title XIX | 31 | |||||||||
32 | Support Surfaces | 32 | |||||||||
33 | Other Ancillary Services | 33 | |||||||||
OUTPATIENT COST CENTERS | |||||||||||
34 | Clinic | 34 | |||||||||
35 | R H C | 35 | |||||||||
36 | Other Outpatient Services | 36 | |||||||||
48 | Ambulance (2) | 48 | |||||||||
75 | Total (Sum of lines 21 - 48) | ### | ### | 75 | |||||||
(1) For titles V and XIX use columns 1, 2 and 4 only. | |||||||||||
(2) Line 48 columns 2 and 4 are for titles V and XIX. No amounts should be entered here for title XVIII. |